Hepatic Cysts Treatment & Management

Treatment of polycystic liver disease (PCLD) or solitary nonparasitic cysts of the liver is indicated only in symptomatic patients. Asymptomatic patients do not require therapy, because the risk of developing complications related to the lesion is lower than the risk associated with treatment.

Patients with hydatid cysts should be treated to prevent complications related to cyst growth and rupture. If cysts on imaging studies show abnormalities suggestive of cystic tumors, resection is indicated. Abscesses should be treated at the time of identification, but percutaneous drainage and antibiotics are usually adequate treatment.

Contraindications to treatment of symptomatic liver cysts relate mainly to underlying comorbid illnesses that increase surgical risk. In particular, congestive heart failure and liver failure with portal hypertension and ascites increase operative risk. Symptoms suggestive of angina or transient ischemic attacks should lead to further preoperative diagnostic studies to identify significant coronary or carotid arterial stenoses.

Guidelines for the management of cystic liver disease have been developed by the European Association for the Study of the Liver (EASL). ^[18] (See Guidelines.)

Simple cysts

No medical therapy has proved effective in reducing the size of simple hepatic cysts. Percutaneous aspiration guided by ultrasonography or computed tomography (CT) is technically simple but has been abandoned because the recurrence rates are nearly 100%. Aspiration combined with sclerosis with alcohol or other agents has been successful in some patients but has high failure and recurrence rates. Successful sclerosis depends on complete decompression of the cyst and apposition of the cyst walls. This is not possible if the cyst wall is thickened or if the cyst is large.

Percutaneous catheters should not be placed to drain simple cysts, because the cavity becomes contaminated, leading to the development of hepatic abscess. Unlike the typical pyogenic hepatic abscess, this problem is difficult to resolve with repeated catheter placements because of continued secretion from the cyst epithelium.

Polycystic liver disease/neoplastic cysts

No options are available for the medical treatment of PCLD or cystadenocarcinoma. Because of the malignant potential of cystadenoma, a role also does not exist for medical therapy for this lesion.

Hydatid cysts

Medical therapy with antihydatid agents (albendazole and mebendazole) is relatively ineffective. These drugs are used as adjuvant treatment, but they do not replace surgical or percutaneous therapy. In surgically treated patients, the use of antihydatid agents is generally given perioperatively; continuation is limited to those who have spillage of cyst fluid at the time of operation or to those with cyst rupture. Antihydatid agents are used in conjunction with percutaneous treatment. Medical therapy should be started 4 days before percutaneous treatment and continued either for 1 month (albendazole) or for 3 months (mebendazole), according to the World Health Organization (WHO) recommendations.

PAIR (puncture, aspiration, injection, reaspiration) is a percutaneous treatment technique for hydatid disease. In this minimally invasive method, a needle is introduced into the cyst under ultrasonographic guidance. Cyst fluid is aspirated and analyzed. Hypertonic saline or ethanol is then injected and reaspirated. PAIRD (puncture, aspiration, injection, reaspiration, drainage) is similar to PAIR except that a catheter is left in place after completion of the procedure. PAIRD is most often used for large cysts.

This percutaneous treatment with sclerosing agents was introduced in the 1980s. Since that time, its use in the treatment of hydatid cysts has been somewhat controversial. However, as this technique has become more common and its safety and efficacy have been reported in the literature, it has been increasingly accepted as a treatment option for hydatid disease. The WHO has supported PAIR as an effective alternative to surgery, though its use is limited.

The WHO recommendations for indications for PAIR are as follows ^[19] :

• Nonechoic lesion greater than or equal to 5 cm in diameter
• Cysts with daughter cysts and/or with membrane detachment
• Multiple cysts if accessible to puncture
• Infected cysts
• Patients who refuse surgery
• Patients who relapse after surgery
• Patients in whom surgery is contraindicated
• Patients who fail to respond to chemotherapy alone
• Children older than 3 years
• Pregnant women

The WHO recommendations for contraindications for PAIR are as follows ^[19] :

• Noncooperative patients
• Inaccessible or risky location of the liver cyst
• Cyst in spine, brain, and/or heart
• Inactive or calcified lesion
• Cyst communicating with the biliary tree

Patients should be followed clinically after PAIR treatment. Recurrence is increased in more complicated cysts, including those with multiple daughter cysts.

PAIR should only be performed in highly specialized centers with appropriately trained and experienced staff. In addition, an anesthesiologist should be present for monitoring and treatment in the event of anaphylactic shock. Surgeons should be notified immediately in case of complication.

Hepatic abscesses

Patients with liver abscesses are immediately started on antibiotics/amebicides. If abscesses are small, patients may respond to medications alone. More likely, these patients will require the addition of percutaneous drainage for eradication.

Simple cysts

Most patients with simple cysts are asymptomatic and require no treatment. When the cysts become large and cause symptoms, such as pain, treatment is warranted. Surgical treatment of simple liver cysts involves "unroofing" the cyst by excising the portion of the wall that extends to the surface of the liver. Excision of this portion of the cyst wall at the liver surface produces a saucer-type appearance in the remaining cyst so that any fluid secreted from the remaining epithelium leaks into the peritoneal cavity where it can be absorbed.

Although ablating the remaining epithelium with electrocautery or an argon beam coagulator is possible, this generally is not required because the volume of fluid secreted each day can be absorbed by the peritoneum without any consequence. Furthermore, ablation of the cyst wall can lead to bleeding or bile leak secondary to injury to underlying vessels and bile ducts. The cyst wall should be sent to pathology to confirm the diagnosis and exclude cystadenoma or cystadenocarcinoma as these lesions require enucleation or formal resection in the setting of cancer.

Historically, treatment of symptomatic hepatic cysts required laparotomy, but today, cyst unroofing can be successfully performed laparoscopically. ^[20] Anecdotal reports of laparoscopic treatment became common by the mid-1990s, and the laparoscopic approach is currently considered the standard of care. ^[21] As compared with laparotomy, this technique is associated with less postoperative pain and disability, shorter duration of hospital stay, and superior cosmetic results.

Polycystic liver disease

In adult PCLD (AD-PCLD), enlargement of the liver occurs slowly and only rarely compromises liver function. Only those patients with clearly disabling pain should be considered for surgery. In patients with PCLD, the surgical goal is to decompress as much of the cystic liver as possible. This can be accomplished by a combination of unroofing and fenestration or, in selected patients, by resection of the involved portion of the liver (see the image below). Recurrence of symptoms with either procedure is high as new cysts replace those that have been resected. Small numbers of patients have been treated with liver transplantation. ^[22]

Neoplastic cysts

Several surgical methods for treatment of cystadenoma and cystadenocarcinoma have been described. Regardless of surgical technique, all surgical options should result in complete ablation of the tumor. Enucleation and formal resection have been accepted as appropriate treatment options. Fenestration and complete fulguration have also been implemented, although, in this method, complete ablation cannot be confirmed by pathology.

Hydatid cysts

All patients with hydatid disease should be considered for percutaneous or surgical treatment because of the risk of life-threatening complications of untreated disease. More complicated cysts are better managed surgically. Treatment of hydatid cysts is associated with two technical problems: (1) risk of anaphylaxis from spillage of cyst fluid containing eggs and larvae into the peritoneal cavity and (2) recurrence caused by residual eggs in incompletely removed germinal membranes. ^[23]

To prevent these problems, most surgeons use a technique in which the cyst contents are aspirated and replaced with a hypertonic saline solution to kill residual daughter cysts in the germinal membrane before unroofing and pericystectomy. ^[24] The goal of the latter procedure is to excise the germinal membrane, leaving the inflammatory and fibrous components of the cyst wall in situ. Attempts to excise the entire cyst wall or to perform formal hepatectomy for hydatid cysts have largely been abandoned because of increased surgical morbidity.

Hepatic abscesses

In general, abscesses are adequately managed by means of antibiotics and percutaneous drainage. If abscesses persist despite attempted percutaneous drainage, surgical drainage is indicated. Other surgical indications include large cysts at risk of rupture and abscesses not anatomically amenable to percutaneous treatment.

Surgical procedure

Prepare patients for general endotracheal anesthesia. Prophylactic antibiotics are not necessary. The patient is positioned supine, with placement of orogastric and bladder catheters to decompress the stomach and bladder. The abdomen is prepared and draped in a sterile fashion.

The operation is begun by inducing pneumoperitoneum with carbon dioxide gas via placement of a Veress needle or Hasson trocar. Generally, three laparoscopic ports are required: one for the telescope with camera, one for retraction, and one to carry out the dissection. The extent of the cyst is usually readily apparent on laparoscopic inspection, but, if not, laparoscopic ultrasonography can be performed to define the cyst anatomy.

The line of the intended unroofing is marked with an electrocautery device, and the cyst excision itself is undertaken with an electrocautery or an ultrasonic or bipolar scalpel. These steps are shown in the images below. Excision of the entire cyst wall is neither necessary nor desired; if attempted, it carries the risk of injury to portal or hepatic venous vessels that may be stretched over the cyst wall.

In cases where the proportion of the cyst wall that can be excised easily is small, omentum should be positioned on a pedicle into the cyst cavity to prevent closure of the roof defect and cyst recurrence. The omentum should be sutured or clipped to the edges of the excision margin. After ensuring that hemostasis is complete, the pneumoperitoneum is desufflated and the trocar sites closed. Waterproof dressings are applied. ^[25]

Technical points

Expose the entire target area (mobilize the liver if necessary), and mark the intended excision line. Begin unroofing at the dependent margin (see the video below).

The ultrasonic scalpel produces less smoke and achieves better hemostasis than the monopolar cautery does.

Saucerize the large cysts (see the video below).

Fill the intraparenchymal cavities with omentum (see the video below).

In patients undergoing laparoscopic unroofing of simple hepatic cysts, the orogastric and bladder catheters can be removed before the patient awakens from anesthesia. A light diet is offered the evening of surgery, and most patients can be discharged home the following day.

Generally, recovery is rapid, and most patients resume full activity within 1 week. Patients can shower with the waterproof dressings in place the day after surgery. The dressings can be removed after 2-3 days.

Complications of laparoscopic unroofing of simple liver cysts are uncommon. Trocar-site infection is a rare occurrence. Unexpected leakage of bile from the cut edges of the cyst can lead to a subhepatic or subphrenic fluid collection or, rarely, bile ascites.

In patients with PCLD, unroofing and fenestration procedures should be performed with care to avoid injury to biliary or vascular structures in the compressed hepatic parenchyma between the cysts.

In patients with hydatid cysts, spillage of cyst contents into the peritoneal cavity, which may cause anaphylaxis, is best avoided.

After successful laparoscopic unroofing of a simple liver cyst, the patient is seen at a follow-up visit within 2 weeks and again 6 weeks after surgery to assess symptomatic relief and to identify complications, such as wound infection or ascites. Routine radiographic studies are not obtained unless symptoms recur.